Basic surgery training to save lives and prevent disability

25 September 2007 | Geneva -WHO is expanding its programme to train health care staff in low- and middle-income countries in essential emergency, basic surgery and anaesthesia skills. The programme, which already exists in 22 countries, will boost the capacity of first-level health facilities (rural or district hospitals and health centres) to deal with simple but essential surgery in a growing number of developing regions.

In many cases, death and permanent disability can be avoided through simple surgical interventions following road traffic injuries, interpersonal violence or war, abdominal emergencies, pregnancy complications, congenital abnormalities, fractures, burns, or the consequences of acute infections.

Together, these conditions cause the loss of approximately 11% of total lost years of healthy life (according to the World Health Report 2002). Injuries alone kill more than 5 million people every year, accounting for nearly one in every 10 deaths worldwide.

The WHO Emergency and Essential Surgical Care Project trains health staff in simple surgical procedures, anaesthesia and emergency care. After training and with the help of basic equipment, health care staff are able to perform surgical procedures that save lives and prevent disability.

New approach to surgery

"The initiative signifies a shift in the way we think about surgery," explains Dr Luc Noel, in charge of clinical procedures at WHO. "Until recently, surgery was a neglected health issue in developing countries because it was assumed to be too expensive and sophisticated."

Surgical intervention has become a common component in the management of patients with HIV/AIDS. Some complications associated with HIV infection (such as abscesses, anorectal disorders, lymphadenopathies, lipoatrophy or mild forms of Kaposi sarcoma) are also diagnosed and treated with simple surgical interventions. Current evidence shows that basic surgical and anaesthetic services should be integrated into primary health-care packages.

"Why should a child die from appendicitis, or a mother and child succumb to obstructed labour, when simple surgical procedures can save their lives?" said Dr Meena Cherian, who heads the surgery programme at WHO.

Barriers to surgical services

The quality of emergency and essential surgical care is often constrained by inadequate basic equipment for interventions that are simple but vital, such as resuscitation, giving oxygen, assessing anaemia and inserting a chest drain.

Other barriers to the timely and appropriate delivery of basic surgical services in low- and middle-income countries include poor infrastructure and insufficient numbers (and training) of health-care professionals.

In most developing countries, adequate surgical services are found only in tertiary centres in urban areas. Furthermore, the migration of health professionals leaves a shortage at primary-health facilities, where services are provided by non-specialist or even non-medical personnel, many of whom are inadequately trained.

However, a number of isolated, local initiatives have shown that even with only basic training and technologies, many lives can be saved or improved. For instance, clubfoot (a congenital deformity of the foot, marked by a twisted position of the ankle, heel and toes) can greatly impede mobility in children. If untreated, clubfoot can lead to severe disability and loss of productive life. Clubfoot is estimated to occur in 1-2 per 1000 live births, which translates into well over 100 000 cases worldwide per year. Clubfoot diagnosed at birth or soon after can often be treated using a minimally invasive technique called the Ponseti method.

Effective, inexpensive techniques

The Ponseti method involves multiple manipulations and plaster castings early in a child's life. Proper implementation of the Ponseti method results in a dramatic decrease in the number of clubfoot cases that require surgery. These techniques have been quite effective in the industrialized world; they require minimal resources and can be implemented by health personnel in primary health-care facilities. Recent programmes in Africa, India and South America are training local health care professionals in the Ponseti technique. In Uganda, over 100 professionals have been trained, resulting in effective treatment of 95% of new cases of clubfoot.

WHO will present future actions of the Emergency and Essential Surgical Care Project to stakeholders and partners at a meeting of the Global Initiative for Emergency and Essential Surgical Care (GIEESC) in Dar-es-Salaam, Tanzania, on 24-25 September. At the meeting, WHO will also seek support from multi-lateral donors to expand the initiative.

WHO established the GIEESC in 2005 to improve access to and quality of surgical care in the developing world. A broad partnership of internationally recognized organizations and individuals, the initiative counts 22 countries representing all WHO regions among its members.

Stakeholders include doctors (surgeons, anaesthetists, paediatricians, obstetricians, nurses), economists, donors, non-governmental organizations, professional societies. A meeting co-hosted by WHO, the World Bank, Global Health Sciences, the Rockefeller Foundation and the Karolinska Institute (Sweden) was held in June 2007 to promote access to surgical services in resource-constrained countries in sub-Saharan Africa.